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‘Keep taking the tablets’
There’s just been some research published showing effective outcomes in quality of life for a group of patients with long term severe mental health problems, who were paid money to keep taking their medication as part of a clinical trial.The idea is superficially attractive. One of the main protective factors for people with major mental illnesses, like schizophrenia, is medication used to manage symptoms. If people stop taking the medication because they don’t feel they need it anymore, then symptoms can re-occur, people start to become unwell, and this may precipitate an admission back to hospital. Mental health policy over the last twenty years has in many ways been about trying to keep people on their medication, for example by developing teams of mental health professionals to work assertively with people who might otherwise drop out of services, and by using the law with such measures as community treatment orders. The recent study into the idea of paying people to keep up with their medication estimated only half of patients stick to their prescriptions. So if paying people (not a lot by the way, £15 per injection in the research study) can keep them out of hospital and out of medical crises, surely the rewards will pay for themselves.
Well, I think there’s a few things wrong with such a suggestion. Psychiatric treatments are often controversial by nature. They can be a protective factor, but there are plenty more things that can help, like having supportive family and friends, regular support and monitoring from mental health teams, reducing stress in people’s lives, and providing meaningful daytime occupation. Can’t we invest more in these factors?
Some anti-psychotic drugs carry risk of side effects like weight gain, if all the incentives are about just taking the tablets (or getting the injections) where is the incentive to have regular reviews of medication, and managed reductions in doses of medication?
People with mental health problems are not alone in sometimes being reluctant to take medication. Many people with physical health problems are equally unhappy about taking medication, or saying they’ll do it to keep family and doctors happy, and then throwing away the tablets. Will there be a demand for payments to encourage everyone to take their prescriptions?
Sometimes clinicians get diagnoses wrong. Patients and their families might be reluctant to query their diagnosis if it means losing the right to medication bonus payments.
There’s a huge pressure on psychiatric in-patient beds at the moment. The House of Commons Health Select committee recently heard evidence from a doctor, that people were being ‘sectioned’ into hospital because beds were in such short supply that hospitals were not admitting people in mental health crisis situations on a voluntary basis.
If paying people to keep taking their medication is shown to keep them out of hospital, I suspect the idea won’t go away soon.
Priebe, S. et al Effectiveness of financial incentives to improve adherence to maintenance treatment with antipsychotics: cluster randomised controlled trial British Medical Journal 7/10/2013